Pneumothorax and pleurodecis

[RStyle]

My wife is 55 and in good health. non smoker. Approximately 10 minutes after a dive she had chest pain which ended up being a pneumothorax. Our profiles had been good and we make a safety stop after every dive. (It is our automatic time to turn camers and strobes off, put cover on dome, fold strobe arms and hang for several minutes.)
She is automatically disqualified from diving.
A chest surgeon (diver) said he could do a pleurodecis which would guarantee that her lung would never collapse again.
So:
1) I have never read anything about diving after pleurodecis
2) Would DAN insure someone after pleurodecis?

 

[DocVikingo]

A chest surgeon (diver) said he could do a pleurodecis which would guarantee that her lung would never collapse again.
So: 1) I have never read anything about diving after pleurodecis and 2) Would DAN insure someone after pleurodecis?

Hi RStyle,

Sorry to hear that.

The procedure to which you are referring is termed "pleurodesis." It typically involves the placement of a chemical irritant into the space between the pleura (the two layers of tissue lining the lungs) in order to create inflammation which tacks the two together, although sometimes such "tacking" my be effected by directly surgically scarring the space. The procedure is intended to obstruct or obliterate the space between the pleura and thus prevent any future accumulation of gas (or fluid). It often does greatly decrease the likelihood of recurrence, but not to zero, and is not to be rushed into and not until after appropriate investigation by and discussion with by a qualified pulmonologist, preferably one at least somewhat knowledgeable in diving medicine.

DAN does not deny dive accident insurance solely on the basis of a pre-existing condition such as pneomothorax (by your description very possibly a tension pneumothorax, a potentially gravely serious event for the diver). This does not, however, mean that DAN automatically believes that someone with such a pulmonary history should in fact engage in SCUBA. You or your wife's pulmonologist are free to contact DAN Scuba Diving Medical Services by phone or email and ask their opinion.

I can tell you that many diving medicine savvy divers would think very carefully about a return to SCUBA following pleurodesis for any type of pneumothorax. Even given a small recurrence rate, if recurrence does occur while diving it could easily be fatal.

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such.

 

[TSandM]

The whole thing with pneumothoraces is to identify the cause. They can be traumatic, as in after car accident or fall. They can be spontaneous, which occurs with lung disease, either congenital or acquired (the latter often being the case with smokers, but can also occur with a variety of underlying soft tissue disorders, like alpha-1 antitryptsin deficiency). Or they can be dive-related, which occurs when someone holds his breath on ascent.

A pleurodesis, as Doc Vikingo writes, substantially decreases the likelihood of a complete lung collapse on the treated side. It does not rule out a lung rupture and gas leakage, but if the pleurodesis is successful, enough of the lung will be adherent to the chest wall that you can't get enough collapse to cause lung function problems or tension physiology (which is what kills people). Still, it is important to know what the cause of the original collapse was, because if it was either congenital abnormalities or acquired lung issues, then the risk of collapse on the UNTREATED side is high. Only if the pneumothorax originally was due to a lapse in diving technique, would I feel comfortable signing the patient off, post pleurodesis, to resume diving. It's not the treated side that's the worry at that point.

 

[RStyle]

Thanks for the responses.
We will be getting a high resolution CT of the chest.
Unfortunately, after more than 600 dives, she may have to stop diving.

 

[DocVikingo]

We will be getting a high resolution CT of the chest.

That is a very appropriate place to start.

Best of luck to your spouse.

Regards,

DocVikingo

 

[Duke Dive Medicine]

Approximately 10 minutes after a dive she had chest pain which ended up being a pneumothorax. Our profiles had been good and we make a safety stop after every dive. (It is our automatic time to turn camers and strobes off, put cover on dome, fold strobe arms and hang for several minutes.)

RStyle,
I'm with TSandM re: discovering the etiology. If this was a spontaneous pneumothorax, then further diving is contraindicated and a pleurodesis may be beneficial. However, the timing is pretty coincidental. Given the time of symptom onset and with lack of evidence to the contrary, this may well have been diving-related. Pulmonary overinflation can occur even in the absence of the classic "panic ascent" dive profile. For example, she could certainly have suffered a pneumothorax if the seas were heavy, the hang bar/down line/anchor line was moving up and down significantly, and she held her breath at the wrong time. If this is the case, then pleurodesis is not indicated and she is not automatically disqualified from diving. I think it's worth discussing this with the thoracic surgeon and possibly getting a second opinion, along with consulting a board-certified hyperbaric physician or a trained diving medical examiner.

Best regards,
DDM

 

[blue sky]

Thanks DocVikingo & TSandM

Truly enlightening for a non-medical type.

 

[Mambo_Diablo]

Hi I am new to diving. I am going to Fiji in a few months and the diving is apparently world class. I'll be staying on the sth west side of Taveuni which is near Rainbow and Vunu reefs.

I am male, 37yrs old in excellent health, but I had a spontaneous pneumothorax on the left side about 7yrs ago whilst doing incline dumbbell press during a gym workout. It was large and had signs of tension. I had a pleurodesis and have had no further complications or incidents since.

I suppose my first course of action if I really want to go diving is to get CT scan. Any other suggestions? It just seems such a shame to miss out on a potentially wonderful nature experience but I think my lovely new wife might get a bit pissed off at me if I die on our honeymoon

ps: I have a PhD in exercise physiology and I studied ventilatory control mechanisms at high altitude, so I'm fairly clued in regarding repiratory physiology, but I'm not a medical doctor and it seems like there are some very knowledgeable and helpful members at this forum.

 

[Duke Dive Medicine]

Mambo,

Unfortunately, any history of spontaneous pneumothorax is an absolute contraindication to diving. You had a pleurodesis on one side, which may be beneficial in preventing the affected lung from collapsing again, but (a) the pleurodesis isn't a 100% guarantee and (b) there is a high incidence of recurrence in the opposite lung. Sorry the news isn't better.

Best regards,
DDM

 

[TSandM]

Unfortunately, Duke Dive Medicine is right. The lifetime recurrence risk for spontaneous pneumothorax is in the 50 to 60 percent range, according to a number of studies. But the risk is not limited to one lung; both sides are generally affected by the abnormalities that caused the original collapse. Since a pneumothorax at depth has a real risk of being a lethal event, it is generally viewed that patients with a history of spontaneous pneumo should not be medically cleared to dive. If you are already certified, I'm rather surprised that you got someone to sign off on your medical.